Intended for healthcare professionals

Rapid response to:

Observations Border Crossing

Copy them in

BMJ 2008; 337 doi: (Published 04 November 2008) Cite this as: BMJ 2008;337:a2324

Rapid Response:

Write to the patient and send the copy to the GP

We welcome Tessa Richards' article about this fundamental issue.
we suggest she does not go far enough.

Adoption of the practice of copying letters to patients has been
limited by
concerns about consent, confidentiality, cost and causing anxiety. Our
experience has been that these concerns are readily overcome if the letter
written to the patient rather than the GP. This has been our routine
since 2005.

Hardly any patients refuse the offer of a letter and many are
grateful to hear
they will receive one. We do not believe that formal consent is necessary
this is not the case for other professions, such as lawyers and bank
managers, who write directly to clients.

We have sought feedback from patients and GPs through questionnaires
out with the letters. Their comments illustrate the benefits: “I
appreciate the
letter addressed to me – the patient.” “I can now understand the
treatment I
am having for my illness and happy to know that I am making some progress
along the way.”

Many patients are unable to recall the verbal information they
receive during
a consultation. “I for one will have forgotten half of what you have told
me by
the time I get home.”

The letters provide useful continuity between clinicians. “Good to
keep the
letter, if you are under different consultants, you can just show them the

letter instead of explaining every time.” “… can update people at work
my progress when they ask.”

The patient is able to alert clinicians to typographical and factual
errors which
can then be corrected. “Wrong post code. 2 medications to be added to
“From 2/9/05 my GP has changed the Pravastatin to Simvastatin.”

The letter is a simple, timely way of passing on the results of tests
during the consultation. “If my appointments are at 2 monthly intervals
knowledge of my current state is always 2 months old as I do not see
until my next appointment”..

Our practice has been welcomed by GP’s: “I asked all my partners
their views
on this ….. Excellent idea to send patients letters.” “Avoids
misunderstandings between what they [patients] think they were told and
what they were.”

A common concern is how to retain important clinical information if
the letter
is written in layman’s terms. Our letters contain a diagnosis or problem
using standard medical terminology. This provides concise information to
other doctors and allows patients to seek further advice from the internet
elsewhere about their diagnosis. The letter highlights important elements
the consultation including proposed investigations, changes in treatment
advice for action. Medical terms are accompanied by lay translations.
are no surprises – all the content of the letter should have been covered
during discussions in the clinic.

A current drugs list is always included, written in plain English
rather than
Latin abbreviations, for example “three times a day” instead of “t.d.s.”.

Changes to drug treatment are highlighted in bold.

Letters are always in English as the cost of professional translation
prohibitive. The letters are printed in large font if the patient is

Hospital doctors have traditionally learned to write clinic letters
by example.
Universal adoption of writing letters to patients will only occur if
training is
incorporated in undergraduate and postgraduate education programmes. We
devoted a departmental teaching session to translating examples of letters
GPs into letters to patients. The trainee doctors present often found
easier than the consultants.

Writing letters to patients has greatly increased both patient
satisfaction and
our professional satisfaction with our outpatient service. Why don’t you
it a try?

Competing interests:
None declared

Competing interests: No competing interests

11 November 2008
Hugh C Rayner
Consultant in Renal Medicine and Medical Director - Medicine
Steve Smith
Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS